The Patho-Mechanics of LBP
The Patho-Mechanics of LBP
The Patho-Mechanics of LBP
OF
LOW BACK PAIN
Hadi Kurniawan
Dept. of Physical Medicine & Rehabilitation
Panti Wilasa “Dr. Cipto” Hospital
Semarang
INTRODUCTION
Functional anatomy
Static Spine
– Physiological curve (relationship to
the plumb line of gravity)
– Lumbo-sacral angle
– Posture
Dynamic spine/ Kinetic spine
Movement of functional unit
Movement of total lumbar spine
Lumbar pelvic rhythm
The Spine
Anatomically:
33 vertebrae: cervical (7), thoracal
(12), lumbar (5), sacrum (5, fused),
cocygeal (4, fused)
Increased in size distally
Most massive in the lumbosacral
region weight-bearing capacity
Functionally:
An aggregate of superimposed
segments functional units (FU)
FU: 2 adjacent vertebral bodies +
intervertebral disk
FU: anterior & posterior segments
Functional Anatomy
Functional Units
Intervertebral disk:
Composed of a central
nucleus (pulposus) enclosed
within an annulus (fibrosus)
A hydrodynamic elastic
structure
“Shock absorbers”
Innervation (-) / aneural
Anterior
Functional Anatomy
Functional Units
Ligaments
Functional Anatomy
Functional Units
Ligaments:
Intervetebral disk reinforce &
protected by the longitudinal
ligaments (anteriorly &
posteriorly)
There is inadequacy of the
posterior longitudinal ligament
in the lower lumbar segment
Posterior longitudinal ligament
Decreasing the protective effect
in the L4, L5, and S1 region
Functional Anatomy
Functional Units
4 groups of Muscles:
Extensors Erector spinae muscles main
Flexors supportive muscles
Lateral flexors
Rotators
Functional Anatomy
Functional Units
Flexors Extensors
LBP: Biomechanical & Patho-Mechanical Aspect
“Specific”
± 5 – 6%
Tumors/ cancers
Infections
± 10 %
Rheumatics
Pancreatitis,
Nephrolithiasis,
etc
Fractures
Osteoporosis
± 4%
Mechanical
± 80% The American College of Physicians and The American Pain Society, 2007
LBP: Biomechanical & Kinesiology Aspect
A. Static LBP
LBP
LBP
Static Spine: Physiologic Curves
Lumbar
Hyperlordosis
Static Spine: Poor/ Faulty Posture
Body Weight
Prolonged Overstretches
of posterior tissues
Flexed Posture
Overstretches of
joint capsules
Intervertebral disk:
Permit compression allowing flexion, extension, lateral flexion,
and rotation
Lateral flexion & rotation occur simultaneously limited in ROM
by the elasticity of the annular colagen fibers
The nucleus deforms to allow all of the motion reamins wihin the
container of the annulus fibrosus
Kinetic Spine
Flexion:
Initiated by the kinetic action of the
abdominal muscles as the main flexor of
the trunk
Muscles of the back (erector spinae)
actively conracts (eccentrically)
provide smooth & controlled movement
and prevent falling
Total ROM of flexion of lumbosacral
spine: 450 75% occuring at L5-S1 &
L4-5
For additional forward flexion a
simultaneous rotation of the pelvis must
occur “lumbar pelvic rhythm”
allowed for a total 800 of flexion
Kinetic Spine
Extension:
Main extensor erector spinae muscles
Limited by mechanical approximation of
the facet joints structure
Kinetic LBP
LBP
(+)
(+)
(–)
(+)
Pathophysiology of Mechanical LBP
Pain
Sustained isometric
Mechanical stress or isotonic Ischemia &
(overuse) contraction of the metabolites
muscles
Nociceptors
Endorphin
Inhibition
Pain
Segmental
spinal reflexes Spasm
Disuse
ROM
Treatment
• Bed rest
• Pharmacologic
• Physical medicine modalities
• Rehabilitation exercises
• Education: proper body mechanics
(PBM)
• Surgical
Summary
• Clinically LBP is evaluated and categorized, on the basis of
biomechanical and pathomechanical aspects of the
lumbosacral spine, as static and kinetic or dynamic LBP.
• Static LBP is LBP that occurs in certain static positions,
without movement, whether sitting or standing. Caused by
deviation of attitude or posture.
• Kinetic LBP occurs due to movements that do not follow the
normal mechanism of the lumbosacral spine.
• Understanding lumbosacral spine as a functional
mechanical structure is the basis for evaluating the
pathomechanism of LBP and provides benefits for
determining and overcoming various problems related to
LBP, including determining a diagnosis and making an
appropriate management programs.